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2 CE creditsThis course was

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Surgical and Prosthetic Implant Treatment of a Maxillary PremolarA Peer-Reviewed Publication Written by Dr. Ian Shuman

AbstractThe diagnosis and extraction of a fractured root is a common occurrence in clinical dentistry. The missing tooth can be restored in a variety of ways. This course will demonstrate the evaluation, treatment planning and implementation of surgical extraction, bone grafting with guided tissue regeneration, implant placement and subsequent restoration of an extracted maxillary second premolar.

Educational Objectives:This clinical study will offer the dental professional the basic steps needed to place and restore a dental implant in the esthetic zone. After reading this article, the reader should be able to:1. Understand the methods used in the

atraumatic extraction of a tooth 2. Plan and execute bone grafting with guided

tissue regeneration 3. Understand the steps used in the surgical

placement of a tissue level dental implant4. Have the ability to restore a dental implant

Author ProfilesDr. Ian Shuman maintains a full-time general, reconstructive, and aesthetic dental practice in Pasadena, Maryland. Since 1995 Dr. Shuman has lectured and published on advanced, minimally invasive techniques. He has taught these procedures to thousands of dentists and developed many of the methods. Dr. Shuman has published numerous articles on topics including adhesive resin dentistry, minimally invasive restorative, cosmetic and implant dentistry. He is a Master of the Academy of General Dentistry, an Associate Fellow of the American Academy of Implant Dentistry, a Fellow of the Pierre Fauchard Academy. Dr. Shuman was named one of the Top Clinicians in Continuing Education since 2005, by Dentistry Today.

Author DisclosureDr. Ian Shuman has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Publication date: Oct. 2012 Expiration date: Sept. 2015

This educational activity was developed by PennWell’s Dental Group with no commercial support.This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content.Requirements for Successful Completion: To obtain 2 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%.CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at hhodges@pennwell.comEducational Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.Registration: The cost of this CE course is $49.00 for 2 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

Supplement to PennWell Publications

PennWell designates this activity for 2 Continuing Educational Credits

Dental Board of California: Provider 4527, course registration number 02-4527-12074“This course meets the Dental Board of California’s requirements for 2 units of continuing education.”

The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to (10/31/2015) Provider ID# 320452.

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Educational Objectives:This clinical study will offer the dental professional the ba-sic steps needed to place and restore a dental implant in the esthetic zone. After reading this article, the reader should be able to:1. Understand the methods used in the atraumatic

extraction of a tooth 2. Plan and execute bone grafting with guided tissue

regeneration 3. Understand the steps used in the surgical placement of a

tissue level dental implant4. Have the ability to restore a dental implant

AbstractThe diagnosis and extraction of a fractured root is a common occurrence in clinical dentistry. The missing tooth can be restored in a variety of ways. This course will demonstrate the evaluation, treatment planning and implementation of surgi-cal extraction, bone grafting with guided tissue regeneration, implant placement and subsequent restoration of an extracted maxillary second premolar.

IntroductionWhen presented with a tooth requiring extraction with re-placement by implant, each stage of the process and future planning for those processes must be carefully considered. The extraction must be performed with maximum bone pres-ervation for the future implant bed, followed by the place-ment of the implant and finally its restoration.

Case HistoryIn this case, a 32-year-old female presented with the chief complaint of pain during function in the maxillary left second premolar. The tooth had a history of root canal therapy and porcelain fused to metal crown. (Figure 1) The crown had been in function for five years. Following a comprehensive ex-amination with radiographs, the occlusion was evaluated and it was determined that there was idiopathic hyperocclusion. The occlusion was adjusted, however the pain persisted. At a subsequent appointment all occlusal contacts were relieved in all paths of function. This did not relieve the symptoms and soon thereafter a buccal fistula developed.

Periodontal probing was within normal limits and a tracer film was taken using gutta percha introduced into the fistulous tract. The radiograph revealed the lesion originat-ing from the mesio-radicular aspect, two-thirds up the root surface. The patient was placed on antibiotic therapy and root canal retreatment was considered. After one week of antibiotic therapy, the patient returned to initiate retreat-ment of the root canal. The possibility of root fracture was discussed and if present, immediate extraction followed by an implant and crown in the future would be necessary. The decision to proceed with implant therapy was made.

At the surgical appointment, the patient was instructed to rinse with a bacteriostatic rinse (Tooth and Gums Tonic, Dental Herb Co.). Typically, antibiotic premedication is given when dealing with sites already infected or requiring as aseptic a technique as possible. Either 2 grams of penicil-lin or 600mg of clindamycin are given orally. Although used for premedicating at risk patients as per the American Heart Association, it is also helpful in all patients to create a spike in blood levels in patients receiving oral surgical care. This patient was already on a course of antibiotic therapy so this was not required. The surgical site was then anesthetized us-ing 1.8cc 4% Citanest Plain (Dentsply Pharmaceutical), fol-lowed by 3.6cc 0.5% Marcaine with epinephrine 1:200,000 (Cooke-Waite) on the buccal and palatal aspects. The crown was sectioned and removed and a fracture was discovered upon chamber access running in a mesio-distal direction extending into the floor of the chamber. The buccal aspect of the tooth demonstrated mobility. It was determined that the tooth was hopeless due to a non-restorable fracture and extraction was initiated.

ExtractionWhen extraction of a tooth is needed in a potential implant site, it is vital to the success of the future implant that the proper amount and density of bone exists. The extraction must be as atraumatic as possible, and any defects in and around the socket must be corrected. To achieve rapid heal-ing for sockets and socket defects, bone grafting and guided tissue regeneration are necessary.

The periodontal ligament was severed circumferentially using a #2 periotome (Karl Schumacher) and several min-utes are allowed to elapse. This promotes bleeding in the periodontal ligament space and creates a hydraulic action that pushes the tooth in a coronal direction. Elevating forces were then placed on the mesial and distal aspects of the root using a specialized elevator, The Periotome (Salvin Dental). This instrument has a specialized purchase point and small handle that prevents fracture using lower torquing forces. A forceps was finally used to remove the tooth with minimal effort. (Figure 2) These surgical tools are used in concert because it is imperative to extract a tooth with minimal damage to the surrounding bone. This bone must be kept whole and undamaged to provide a future implant site.

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The socket was then evaluated for any imperfections and a 5mm fenestration was discovered on the buccal aspect, approximately 10mm apical to the crest of bone. This was due to the buccal fistula that had formed as a result of the fractured root. Granulomatous tissue was curetted using a spoon excavator enucleating the infected site. Next, the socket walls on the palatal, mesial and distal were perforated to a depth of 1mm with a #2 surgical length round bur (SS White) to induce blood flow. This new blood flow contains osteprogenitor cells that will greatly aid in the bone grafting process. A resorbable guided tissue membrane, RCM6 (Ace Surgical) was placed against the buccal wall. The method of Guided Tissue Resorption is vital in assisting complete bone regrowth in socket walls when a defect is present. Without it, the soft tissue, which has a greater rate of growth than bone will invade the socket and prevent future implant placement.

Bone GraftingA small particle (250-1000 mic.) cancellous particulate hu-man bone allograft (alloOss, Ace Surgical) was hydrated in sterile water and placed into the socket. Resorbable collagen tape (Ace Surgical) was placed over the socket and a figure eight suture was placed using 4.0 chromic gut. Prescrip-tions were written to aid in post-operative healing and pain management, home care instructions were given orally and written and the patient dismissed. The patient was seen at 10 days post-op for evaluation.

Evaluation of site for implant sizeWhen considering an implant as a restorative choice, the size of the three-dimensional bony site must be deter-mined. (Figure 2) There are several methods to determine whether the site is ideal, from the simple to the more com-plex. These include but are not limited to visual inspection, digital palpation, periodontal probing, the use of bone cali-pers, radiographs, CT scan, and cone beam computerized technology.

This case will focus on basic, cost effective evaluation methods for the single site implant. Perhaps the easiest

method for determining the status of the implant site is a combination of radiographs and bone calipers. Because the implant occupies a three-dimensional space, three measure-ments are needed: horizontal distance between the adjacent roots, vertical height of available bone, and the width or thickness of the available bone.

Bone Mapping: Horizontal and vertical spaceA radiograph of a single site can be used to measure the two-dimensional distances between the adjacent roots, and the vertical length or height of available bone. The mini-mum distance between the implant and adjacent root is 1.5 -2.0mm and between adjacent implants; 3.5-4mm. This provides an adequate amount of inter-implant-radicular bone space necessary for an adequate blood supply. This blood supply is required to nourish the periodontal liga-ment of adjacent tooth roots and bone of adjacent implants and the bone surrounding the new implant with the cells required for creating osseointegration of the titanium-bone interface. Encroaching on this space will compromise the blood supply and potentially damage the periodontal liga-ments.

Bone Mapping: WidthThe bucco-lingual width of available bone can be deter-mined with a bone caliper taking regular measurements in the mouth, from the most coronal aspect of the edentulous surgical site to the desired apical height. In addition, probing the periodontal spaces of adjacent teeth will aid in determin-ing the health of the site. Any periodontal therapy needed for the adjacent teeth can be performed prior to implant surgery and the site reevaluated following healing.

Implant size selection:Based on the above measurements, the size of the implant needed can then be determined. In this case, a conical self-threading screw type implant was selected (Biodenta). Measurements of the implant bed were taken based on the above criteria and the results were as follows:

Horizontal: 10.5mm (between adjacent root/implant)Vertical: 13.3mm (from crest to below the maxillary sinus)Width: 7.8mm (from palatal to buccal at the narrowest point) Implant size selected: 3.5mm wide by 10mm long

The horizontal size of the implant was based on sub-tracting 2mm from the adjacent root and 4mm from the adjacent implant. Based on these calculations there was 4.5mm of space leaving adequate space for a 3.5mm im-plant. The vertical length of 10mm of the implant was based on the height of the adjacent root/implant and it simply is not necessary to place an implant with any considerable length beyond this. There must be sufficient bone to house the 3.5mm wide implant. A 7.8mm bone width provides

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more than adequate space for this. Because this case was located in the posterior, and there was a sufficient amount of soft tissue, a tissue level implant was selected.

Implant Type Selection: Tissue Level vs. Bone LevelWhile this article is by no means an official guide to implant types and their variations in design, the following should offer a brief review of the basics of these two varieties of implants. (See table 1)

Table 1 image a: Tissue Level

1. Short neck area of 1.5 mm

2. Gentle cortical area for smooth osseointegration

3. Cylindrical core area for precise positioning

4. Self-cutting thread

5. Sharp and conical screw head for easy placement

6. Safe and reliable connection with abutment done by octagonal connection

Table 1 image b: Bone Level

1. Tight Fit Connection – tight and stable

2. Cylindrical core area for precise positioning

3. Internal thread for stable osseointegration

4. Self-cutting thread

5. 6° conical hex connection system

6. Platform switching

Bone level implant pros and cons: 1. The bone level implant, as its name suggests, is placed

to the crest of the bone or slightly subosseous. 2. It is best used in anterior tooth replacement where

aesthetics are a concern, but can be also used in any other position in the arch.

3. This type of implant offers a wide range of options when designing an abutment and has great flexibility in correcting a less than desirable implant angulation.

4. Unless a healing cap is placed at the time of surgery, a second stage surgical procedure is required to access the implant.

5. The implant-abutment interface is at the level of crestal bone or slightly sub-osseous

6. A micro-gap between the implant and the abutment has been identified.

7. This micro-gap has been implicated in the bone loss known as saucerization that occurs in the first two millimeters of the crestal bone.

Tissue level implant pros and cons1. The tissue level implant is placed to the crest of the

bone with the polished collar extending coronally, housed in soft tissue.

2. The tissue level implant is ideal in the posterior. 3. The gingival margin and emergence profile of the

tissue level implant is already built in to the implant. 4. Since the abutment-implant interface is above the

crestal level of bone, the problem of bone loss as with a micro-gap in the bone level implant is eliminated.

5. This type of implant does not require surgical recovery, which is commonly necessary with a bone level implant.

Surgical Treatment: PreparationAt the surgical appointment, the patient was instructed to rinse her mouth with a bacteriostatic rinse (Tooth and Gums Tonic, Dental Herb Co.). She was given 600mg clindamycin and 800mg Motrin orally. As previously men-tioned it has been found helpful in all patients to create a spike in blood levels with an antibiotic in patients receiving oral surgical care. The surgical site was then anesthetized using 1.8cc 4% Citanest Plain (Dentsply Pharmaceuti-cal), followed by 3.6cc 0.5% Marcaine with epinephrine 1:200,000 (Cooke-Waite) on the buccal and palatal aspects. (Figure 3)

Figure 3.

Flap SelectionAn incision was made along the crest of the ridge from mesial to distal. The incision was made vertically, avoiding the pa-pillae and extending several millimeters into the mucogingiva on the buccal. Because a tissue level implant was used, this type of flap is necessary. Although this case could have been accomplished without an incision, there is no substitute for direct visualization of the surgical site and complete evalua-tion of the bone. In addition, evaluation of the guided tissue healing could be directly evaluated and further repair made if necessary.

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OsteotomyA full thickness flap was raised using a periodontal elevator. With the flap reflected, the bony crest was evaluated. At this point, the success of the guided tissue and bone graft was observed. A 3mm surgical length round bur was used to create an initial depression or dimple in the crestal bone. This was followed by drilling into the bone to a depth of 4mm using a guide drill followed by a 2mm pilot drill to the same depth. A parallel pin was placed and a radiograph taken to determine the mesio-distal angulation: this is the time to make a course correction, if necessary, allowing some flexibility in the creation of the osteotomy.

Once correct angulation was determined, a depth of 8mm was made using the pilot drill followed again by radiograph with the parallel pin. If the osteotomy is made correctly, the pilot drill is taken to depth, in this case 10mm. The osteotomy was then widened with a 2.8mm drill to the desired predetermined implant length. In general maxillary bone is less dense than mandibular bone and care must be taken not to over-widen the osteotomy. In a newly grafted site the bone is even softer so further widening of the oste-otomy was not necessary. A 3.5mm profile drill was used to create a countersink.

Primary stabilization of the implant is achieved through tight contact with the osteotomy. The self-cutting threads of the implant engage this bone, allowing osseointegration to occur during the healing phase. A 3.5mm tissue level im-plant was selected and screwed into the osteotomy. (Figure 4,5,6) The implant holder was unscrewed (Figure 7) and a radiograph was taken to verify ideal placement and dis-tances from various periodontal anatomic landmarks that will provide a successful outcome. (Figure 8)

The cover screw was seated to place and the flap sutured around the tissue level collar using 4.0 chromic gut. Provi-sional tooth replacement was not necessary as this area was not visible when the patient smiled. In addition, immediate provisionalization can create movement of the implant, compromising osseointegration. Prescriptions were writ-ten to aid in post-operative healing and pain management,

Figure 5.

Figure 6.

Figure 7.

Figure 8.Figure 4.

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home care instructions were given orally and in written form and the patient dismissed. The patient was seen ten days later for post-op evaluation.

Definitive ProstheticsAfter ninety days the case was ready for a final impression. (Figure 9) Following cover screw removal (Figure 10) a final impression was made of the transfer using polyvinyl siloxane (Honigum, Zenith Dental). There are two impres-sion methods for dental implants: closed tray and open tray techniques.

The closed tray technique uses an implant impression coping that is at the same general occlusal height as the ad-jacent teeth allowing it to fit comfortably within the housing of a standard impression tray. (Figure 11)

The open tray technique uses an implant impression cop-ing that extends well beyond the occlusal height of adjacent teeth. (Figure 12,13) A cutout is made in the tray (hence the name open tray) to allow for the elongated impression copings to extend through the tray, providing unencumbered access to the screw hole. (Figure 14,15) This technique is required most often when multiple implants are being impressed. The open tray technique works as follows: the impression coping is screwed to place and a cotton pellet is placed in the access hole followed by a small ball of beading, orthodontic or similar wax and the impression is made. (Figure 16) Once the impression material is set, the screw hole is accessed by removing the wax and cotton, and the screw is removed. (Figure 17) The impres-sion is then removed essentially acting as a pick up impression for the coping. This prevents movement of the coping, thus maintaining the exact location of the implant.

Figure 9.

Figure 10.

Figure 11.

Figure 12.

Figure 13.

Figure 14.

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Because of the limited posterior inter-occlusal space between opposing arches, a screw retained titanium-to-por-celain crown was prescribed. Upon receipt of the definitive laboratory fabricated crown, it was torqued to 30Ncm as per manufacturer’s specifications. A radiograph was then taken to ensure complete seating and the occlusion evaluated. Occlusal contact was evaluated in maximum intercuspation and all excursive movements were eliminated. The abut-ment screw hole was filled with a cotton pellet and the access hole closed with direct composite. (Figure 18,19) To ensure a successful outcome the occlusion was evaluated a second time. (Figure 20,21)

Figure 15.

Figure 16.

Figure 17.

Figure 18.

Figure 19.

Figure 20.

Figure 21.

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SummaryThe ability to diagnose and treatment plan the restoration of a fractured tooth is a necessary function in daily clinical dentistry. Presenting the treatment option of extraction with implant replacement to the patient is a must and should always be considered. Practitioners should always present their patients with an entire array of treatment options list-ing all of their positive and negative attributes.

Author ProfilesDr. Ian Shuman maintains a full-time general, reconstruc-tive, and aesthetic dental practice in Pasadena, Maryland. Since 1995 Dr. Shuman has lectured and published on ad-vanced, minimally invasive techniques. He has taught these procedures to thousands of dentists and developed many of the methods. Dr. Shuman has published numerous articles on topics including adhesive resin dentistry, minimally in-vasive restorative, cosmetic and implant dentistry. He is a Master of the Academy of General Dentistry, an Associate Fellow of the American Academy of Implant Dentistry, a Fellow of the Pierre Fauchard Academy. Dr. Shuman was named one of the Top Clinicians in Continuing Education since 2005, by Dentistry Today.

Author DisclosureThe author of this course has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Reader FeedbackWe encourage your comments on this or any PennWell course. For your convenience, an online feedback form is available at www.ineedce.com.

Notes

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Online CompletionUse this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

Questions

1. In this case, the buccal fistula was caused by:a. traumab. hyperocclusal forcesc. root fractured. sinus inflammatory response

2. The open tray technique uses an implant impression coping that… a. extends well beyond the occlusal height of

adjacent teethb. is housed within the impression trayc. requires an intact impression trayd. is limited to specific implant cases

3. All of the following instruments were used for an atraumatic extraction except:a. periotomesb. periotome elevatorc. forcepd. surgical round bur

4. In the bone level implant, bone loss known as saucerization is due to ___________ .a. micro-gapb. poorly placed implantc. soft maxillary boned. platform switching

5. Saucerization has been seen to occur in the first _____ millimeters of the crestal bone.a. 1.5b. 2.0c. 3.5d. 4.0

6. Which of the following is the correct sequence of events when using an open tray impression technique?a. A cotton pellet is placed in the access hole followed

by a small ball of wax, the impression coping is screwed to place, the screw holes are accessed after the impression is set and the impression is removed.

b. The impression coping is screwed to place, the screw holes are accessed and lightly unscrewed, a cotton pellet is placed in the access hole followed by a small ball of wax and after the impression is set the impression is removed.

c. The impression coping is screwed to place, the screw holes are accessed and screwed with double the torque force recommended, a cotton pellet is placed in the access hole followed by a small ball of wax and after the impression is set the impression is removed.

d. The impression coping is screwed to place, a cotton pellet is placed in the access hole followed by a small ball of wax, the screw holes are accessed after the impression is set and unscrewed and the impression is removed.

7. One of the positive aspects of a bone level implant is:a. second stage surgery is required to access the

implantb. the micro-gap between the implant and abutment c. a. and b.d. none of the above

8. One of the negative aspects of a tissue level implant is a. it is ideal in the posterior. b. The gingival margin and emergence profile of the

tissue level implant is already built in to the implant.c. Since the abutment-implant interface is above

the crestal level of bone, the problem of bone loss as with a micro-gap in the bone level implant is eliminated.

d. None of the above.

9. To aid in bone grafting, the socket walls are perforated bringing in new blood flow containing what type of cells? a. mesenchymalb. osteoclastsc. osteoprogenitord. a. and c.

10. Which of the following is used to prevent soft tissue in-growth when bone grafting an extraction socket?a. bone waxb. guided tissue membranec. bone chipsd. all of the above

11. In this case, what size was the small particle cancellous particulate human bone allograft? a. 250-1000 mic.b. 500-1000 mic.c. 250-500 mic.d. 500-1250 mic.

12. Here, the particulate human bone allograft was hydrated in: a. sterile waterb. salinec. bloodd. none of the above

13. The self-threading implant will com-press against bone resulting in primary stabilization of the implant. That is why it is important to: a. undersize the final width of the osteotomyb. oversize the final width of the osteotomyc. match the diameter of the osteotomy to the

implantd. b and/or c

14. Which of the following should not be used to determined whether a site is indeed a good candidate for implant?a. a comprehensive examination with radiographs

b. periodontal charting

c. bone mapping

d. none of the above

15. When placing a tissue level implant, what type of flap was used due to its polished tissue collar?a. full thickness ridge incision

b. punch

c. papillae sparing

d. z-plasty

16. The minimum distance between the implant and adjacent roots is:a. 1.0-2.0mm

b. 3.0-4.0mm

c. 1.5-2.5mm

d. 1.5–2.0mm

17. The minimum distance between the implant and adjacent implants is:a. 2.0-2.5mm

b. 2.5-3.0mm

c. 3.0-3.5mm

d. 3.5–4.0mm

18. In this clinical case, which of the follow-ing was used to determine the width of available bone?a. MRI

b. CT Scan

c. bone caliper

d. periapical radiograph

19. Bone grafting and guided tissue regeneration is necessary for:a. rapid healing

b. encouraging the induction of osteoprogenitor cells

c. advancing the growth of soft tissue

d. all of the above

20. When faced with limited posterior inter-occlusal space between opposing arches, which of the following is used: a. bone level implant

b. separate short abutment and crown

c. cast crown only

d. screw retained crown

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ANSWER SHEET

Surgical and Prosthetic Implant Treatment of a Maxillary Premolar

Name: Title: Specialty:

Address: E-mail:

City: State: ZIP: Country:

Telephone: Home ( ) Office ( ) Lic. Renewal Date:

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822

AGD Code 496, 616

Educational Objectives1. Understand the methods used in the atraumatic extraction of a tooth

2. Plan and execute bone grafting with guided tissue regeneration

3. Understand the steps used in the surgical placement of a tissue level dental implant

4. Have the ability to restore a dental implant

Course Evaluation1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No

Objective #2: Yes No Objective #4: Yes No

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0

9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0

10. Do you feel that the references were adequate? Yes No

11. Would you participate in a similar program on a different topic? Yes No

12. If any of the continuing education questions were unclear or ambiguous, please list them. ___________________________________________________________________

13. Was there any subject matter you found confusing? Please describe. ___________________________________________________________________ ___________________________________________________________________

14. How long did it take you to complete this course? ___________________________________________________________________ ___________________________________________________________________

15. What additional continuing dental education topics would you like to see? ___________________________________________________________________ ___________________________________________________________________

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